XI.

HEALTH HISTORY GUIDELINES

a. Purpose of Interview

1.Gather organized, complete and accurate data about the patient’s health state, including

the description and chronology of any signs and symptoms of illness.

2.Establish rapport and trust so the patient feels accepted and thus feel free to share all

relevant data

3.Teach the patient about the health state so that he/she can participate in identifying

problems and planning for health care

4.Build rapport for a continuing nurse—patient therapeutic relationships; this rapport

facilitates future diagnoses, planning and treatment.

5.Begin teaching for health promotion and disease prevention

b. Phases of Interview

1.Preinteraction/Preparatory Phase:

 Review as much information as possible about the patient

 Decide what data are needed and what type of data collection form will be used

 Review the literature pertinent to the patient’s developmental age, psychosocial aspects

and pathophysiological consideration if needed

  Assess own feelings or reactions to previous patients that might interfere with the nurse-

patient relationship

 Seek assistance from more experienced nurses, mentors or supervisors as needed.

 Plan for a private, quiet setting for the interview, schedule a mutually convenient time of

day; and determine the length of time needed for data collection.

 Modify the environment to facilitate the interview.

2. Introductory Phase

Aka the orientation phase. Begins when the nurse and the patient meet.

Actions in this phase assist in establishing rapport, clarifying roles and alleviating

anxiety.

a. Introduce self by name and position and explain the purpose and content of the

interview

e.g., My Yllana, I’m Josie Udan, I’m a nurse. I would like to talk about your

illness that caused you to come to the hospital.

Mrs. Agpalza, I want to ask you some questions about your health so that we can

identify what is keeping you healthy and explore any problems.

b. Begin to establish rapport with the patient by conveying a caring, interested attitude.

Rapport is essential for a trusting, helpful nurse patient relationship.

e.g., Tell me how I can help you.

 Tell me why you have come here today

What brings you to the hospital.

c. Observe the patient’s behavior and listen attentively to determine the patient’s self-

perceptions and how the patient view his or her health problems. Validate the patient’s

perceptions as the interview progresses

d. Let the patient know how long the nurse-patient relationship is expected to last

e.g., I will be your nurse for today, from 7am to 7pm.

e. Inform the patient how the information collected will be used and that confidentiality

will be maintained.

e.g., The information that we collected from you will be used in planning your

care. We reassure you that these will be kept confidential.

f. Start with non-threatening, specific questions and proceed to open-ended questions

e.g., How have you been getting along?

How have you been feeling since your last appointment?

g. Establish a verbal contract with the patient, incorporating the goals of the interview.

3. Maintenance Phase

Aka the WORKING PHASE

The nurse and the patient work toward achieving the specific task or goal agreed

on in the introductory phase

 a. Keep focused on the tasks or goals to ensure that the needed data are obtained

and goals are achieved.

b. Encourage the patient to express his or her feelings, concerns and questions

c. Use techniques that facilitate communication between the nurse and patient

(e.g., silence, general leads, validations)

d. Observe the nonverbal behavior that accompanies verbal responses (e.g., a

patient may say she is not nervous, worried, or anxious while fidgeting or biting

her fingernails, moving constantly or smoking throughout the interview)

e. Assess the patient’s ability to continue the interview (e.g., grimace of pain,

shortness of breath, fatigue)

f. Facilitate goal attainment by moving to the next step of discussion after needed

data are collected.

3. Maintenance Phase

TWO TYPES of Questions Used During Interview:

a. Closed-ended

- (direct) questions yield “yes” or “no” answers.

- important in emergencies or when a nurse needs to establish basic facts

- Asks for specific information, elicits a short, one-or-two word answer, a yes or no, or a

forced choice (choices are given)

 - Limits rapport and leaves interaction neutral

e.g., “Do you have a family history of heart disease?”

“Have ever had pain?”

“Do you smoke?”

b. Open-ended questions

-require patients to elaborate; narrative information

-broad and provide responses in the patient’s own words; the person is free to answer in

any way

-lets the person express herself or himself fully

-builds and enhances rapport

- the key to understanding symptoms, health practices, and areas requiring intervention

e.g., Tell me how can I help you?

What brings you to the hospital?

You mentioned shortness of breath, tell me about that.

How have you been feeling since your last appointment?

c. Communication Process

Using medical terminology, abbreviations, or jargon not known to patients interferes with

the communication process. Some examples include saying “hypertension” instead of “high
blood pressure,” “dysphagia” rather than “difficulty in swallowing,” “CVA” rather than “stroke,”

or “myocardial infarction” rather than “heart attack.” Using medical terminology might confuse

the patients, lead them to misunderstand the question, or cause them to feel too embarrassed to

ask for clarification. Such a scenario can lead to inaccurate data collection.

d. Therapeutic Communication

Therapeutic communication - a basic nursing tool in which the nurse ensures that the

interaction focuses on the patient and the patient’s concerns.

KEY ELEMENTS:

a. Caring - the ability to connect with the patient and demonstrate

compassion, sensitivity, and patient-centered care.

b. Empathy – ability to perceive, reason, and communicate understanding of another person’s

feelings without criticism.

- It is being able to see and feel the situation from the patient’s perspective, not the nurses.

d.1 Nonverbal Communication Skill

Appearance

First take care to ensure that your appearance is professional. The client is expecting to

see a health professional; therefore, you should look the part. Wear comfortable, neat clothes and
a laboratory coat or a uniform. Be sure that your nametag, including credentials, is clearly

visible. Your hair should be neat and not in any extreme style; some nurses like to wear long hair

pulled back Fingernails should be short and neat jewelry should be minimal.

Demeanor

Your demeanor should also be professional. When you enter a room to interview a client,

display poise. Focus on the client and the upcoming interview and assessment. Do not enter the

room laughing loudly, yelling to a coworker, or muttering under your breath. This appears

unprofessional to the client and will have an effect on the entire interview process. Greet the

client calmly and focus your full attention on her. Do not be overwhelmingly friendly or

"touchy": many clients are uncomfortable with this type of behavior. It is best to maintain a

professional distance

Facial Expression

Facial expressions are often an overlooked aspect of communication. Because facial

expressions often show what you are truly thinking (regardless of what you are saying), keep a

close

check on them. No matter what you think about a client or what kind of day you are

having, keep your expression neutral and friendly. If your face shows anger or anxiety, the client

will sense it and may think it is directed toward him or her If you cannot effectively hide your

emotions, you may want to explain that you are angry or upset about a personal situation.
Admitting this to the client may also help in developing a trusting relationship and genuine

rapport.

Attitude

One of the most important nonverbal skills to develop as a health care professional is a

nonjudgmental attitude. All clients should be accepted, regardless of beliefs, ethnicity, life- style,

and health care practices. Do not act as though you feel superior to the client or appear shocked,

disgusted, or surprised at what you are told. These attitudes will cause the client to feel

uncomfortable opening up to you and important data concerning his or her health status could be

withheld.

Silence

Another nonverbal technique to use during the interview pro- cess is silence. Periods of

silence allow you and the client to reflect and organize thoughts, which facilitates more accurate

reporting and data collection

Listening

Listening is the most important skill to learn and develop fully in order to collect

complete and valid data from your client. To listen effectively, you need to maintain good eye

contact, smile or display an open, appropriate facial expression, maintain an open body position

(open arms and hands, and lean forward). Avoid preconceived ideas or biases about your client.
To listen effectively, you must keep an open mind. Avoid crossing your arms, sitting back, tilting

your head away from the client, thinking about other things, or looking blank or inattentive.

Becoming an effective listener takes concentration and practice.

NONVERBAL COMMUNICATION TO AVOID

Excessive or Insufficient Eye Contact

Avoid extremes in eye contact. Some clients feel very uncomfortable with too much eye

contact; others believe that you are hiding something from them if you do not look them in the

eye. Therefore, it is best to use a moderate amount of eye contact. For example, establish eye

contact when the client is speaking to you but look down at your notes from time to time. A

client's cultural background often determines how he feels about eye contact (see Cultural

Variations in Communication section for more information).

Distraction and Distance

Avoid being occupied with something else while you are asking questions during the

interview. This behavior makes the client believe that the interview may be unimportant to you.

Avoid appearing mentally distant as well. The client will sense your distance and will be less

likely to answer your questions thoroughly. Also try to avoid physical distance exceeding 2 to 3

feet during the interview. Rapport and trust are established when the client senses your focus and
concern are solely on the client and the client's health. Physical distance may portray a noncaring

attitude or a desire to avoid close contact with the client.

Standing

Avoid standing while the client is seated during the interview. Standing puts you and the

client at different levels. You may be perceived as the superior, making the client feel inferior.

Care of the client's health should be an equal partnership between the health care provider and

the client. If the client is made to feel inferior, he or she will not feel empowered to be an equal

part- ner and the potential for optimal health may be lost. In addition, vital information may not

be revealed if the client believes that the interviewer is untrustworthy, judgmental, or

disinterested.

Biased or Leading Questions

Avoid using biased or leading questions. These cause the cli- ent to provide answers that

may not be true. The way you phrase a question may actually lead the client to think you want

her to answer in a certain way. For example, if you ask "You don't feel bad, do you?" the client

may conclude that you do not think she should feel bad and will answer "no" even if this is not

true.

Rushing Through the Interview

 Avoid rushing the client. If you ask questions on top of ques- tions, several things may

occur. First, the client may answer "no" to a series of closed-ended questions when he or she

would have answered "yes" to one of the questions if it was asked individually. This may occur

because the client did not hear the individual question clearly or because the answers to most

were "no" and the client forgot about the "yes" answer in the midst of the others. With this type

of inter- view technique, the client may believe that his individual situation is of little concern to

the nurse. Taking time with clients shows that you are concerned about their health and helps

them to open up.

Reading the Questions

Avoid reading questions from the history form. This deflects attention from the client and

results in an impersonal inter- view process. As a result, the client may feel ill at ease open- ing

up to formatted questions

d.2 Verbal Communication Skill

Open-Ended Questions

Open-ended questions are used to elicit the client's feelings and perceptions. They

typically begin with the words "how" or "what." An example of this type of question is: "How

have you been feeling lately?" These types of questions are important because they require more

than a one-word response from the client and, therefore, encourage description. Asking open-

ended questions may help to reveal significant data about the client's health status.
Closed-Ended Questions

Use closed-ended questions to obtain facts and to focus on specific information. The

client can respond with one or two words. The questions typically begin with the words "when"

or "did." An example of this type of question is: "When did your headache start?" Closed-ended

questions are useful in keeping the interview on course. They can also be used to clarify or

obtain more accurate information about issues disclosed in response to open-ended questions.

For example, in response to the open-ended question "How have you been feeling lately?" the

client says, "Well, I've been feeling really sick to my stomach and I don't feel like eating because

of it." You may be able to follow up and learn more about the client's symptom with a closed-

ended question such as "When did the nausea start?"

Laundry List

Another way to ask questions is to provide the client with a list of words to choose from

in describing symptoms, conditions, or feelings. This laundry list approach helps you to obtain

spe- cific answers and reduces the likelihood of the client perceiv- ing or providing an expected

answer. For example, "Is the pain severe, dull, sharp, mild, cutting, or piercing?" "Does the pain

occur once every year, day, month, or hour?" Repeat choices as necessary

Rephrasing

Rephrasing information the client has provided is an effective way to communicate

during the interview. This technique helps you to clarify information the client has stated; it also

enables you and the client to reflect on what was said. For example, your client, Mr. G., tells you

that he has been really tired and nauseated for 2 months and that he is scared because he fears
that he has some horrible disease. You might rephrase the information by saying "You are

thinking that you have a serious illness?"

e. Non-therapeutic Responses

Patients may express a variety of emotions during an interview such as sadness, fear, or

anger. Crying is a natural emotion. Saying, “Don’t cry” is not a therapeutic response. A

therapeutic approach is to provide tissues and let patients know that it is all right to cry by giving

a response such as, “Take all the time you need to express your feelings.” Postpone further

questioning until the patient is ready. Crying may indicate a need that can be addressed at a later

time. A compassionate response to a patient who is crying demonstrates caring and may enhance

the nurse patient relationship.

Non-therapeutic Technique

1. Overloading

 talking rapidly, changing subjects too often, and asking for more information than can be

absorbed at one time.

 “What’s your name? I see you like sports. Where do you live?”

2. Value Judgments

 giving one’s own opinion, evaluating, moralizing or implying one’s values by using words

such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.

 “You shouldn’t do that, its wrong”.

3. Incongruence

 sending verbal and non-verbal messages that contradict one another.

 The nurse tells the patient “I’d like to spend time with you” and then walks away.

4. Underloading

 remaining silent and unresponsive, not picking up cues, and failing to give feedback.

 The patient ask the nurse, simply walks away.

5. False reassurance/ agreement

 Using cliché to reassure client.

 “It’s going to be alright”.

6. Invalidation

 Ignoring or denying another’s presence, thought’s or feelings.

 Client: How are you?

 Nurse responds: I can’t talk now. I’m too busy.

7. Focusing on self

 responding in a way that focuses attention to the nurse instead of the client.

 “This sunshine is good for my roses. I have beautiful rose garden”.

8. Changing the subject

 introducing new topic

 inappropriately, a pattern that may indicate anxiety.

 The client is crying, when the nurse asks “How many children do you have?”

9. Giving advice

 telling the client what to do, giving opinions or making decisions for the client,

implies client cannot handle his or her own life decisions and that the nurse is accepting

responsibility.

 “If I were you… Or it would be better if you do it this way…”

10. Internal validation

 assuming about the meaning of someone else’s behavior that is not validated by the other

person (jumping into conclusion).

 The nurse sees a suicidal client smiling and tells another nurse the patient is in good mood.

Other ineffective behaviors and responses:

1. Defending – Your doctor is very good.

2. Requesting an explanation – Why did you do that?

3. Reflecting – You are not supposed to talk like that!

4. Literal responses – If you feel empty then you should eat more.

5. Looking too busy.

6. Appearing uncomfortable in silence.

7. Being opinionated.

8. Avoiding sensitive topics

9. Arguing and telling the client is wrong

10. Having a closed posture-crossing arms on chest

11. Making false promises – I’ll make sure to call you when you get home.

12. Ignoring the patient – I can’t talk to you right now

13. Making sarcastic remarks

14. Laughing nervously

15. Showing disapproval – You should not do those things.

XII. HEALTH HISTORY SOURCES

a. Primary and Secondary Data Sources

Primary Data or Sources

Client is a source of data

Secondary Data or Sources

Family members or other support persons, health team members,

Health records (medical records, laboratory and diagnostic analyses, and relevant

literature)

b. Reliability of the Source

Reliability

 Varies according to patient’s memory, trust, and mood

 Record who furnishes the information (e.g., the patient, relative or friend)

 Judge how reliable the information seems and how willing he or she is to communicate.

 Note any circumstances such as the use of interpreter

Example: Patient herself, who seems reliable

Patient’s son, Joseph Peter, who seems reliable

Ms. Ling Nam, interpreter for Sun Jing who does not speak Filipino or

English, speaks Chinese only

XIII. COMPONENTS OF THE HEALTH HISTORY

a. Demographic Data

 Full name

 Address and telephone numbers

 Birth date and birth place.

 Sex

 Religion and race.

 Marital status.

 Social security number.

 Occupation

 Source of referral

 Usual source of healthcare.

 Source and reliability of information.

 Language and communication needs

 Date of interview.

b. Reason for Seeking Care (chief complaints)

Examples of chief complaints:

 Chest pain for 3 days.

 Swollen ankles for 2 weeks.

 Fever and headache for 24 hours.

  Pap smear needed.

 Physical examination needed for camp.

The CC is enclosed in quotation marks to indicate the person’s exact words.

The CC is not a diagnostic statement. Avoid translating it into terms of a medical diagnosis

(e.g., “increasing shortness of breath for 4 hours” not “emphysema”)

C. History of Present Illness

 Gathering information relevant to the chief complaint, and the client's problem,

including essential and relevant data, and self-medical treatment.

Example: “Please tell me all about your headache, from the time it started until the

time you came to the hospital.”

 Components of Present Illness

 Introduction: "client's summary and usual health".

 Investigation of symptoms: "onset, date, gradual or sudden, duration,

frequency, location, quality, and alleviating or aggravating factors".

 Negative information.

 Relevant family information.

  Disability "affected the client's total life".

 The final summary of any symptom should include the following eight critical

characteristics:

a. Location. E.g., pain- “pain behind the eyes”, “jaw pain”, “Is the pain localized to

this site, or radiating?”, “Is the pain superficial or deep?”

b. Quality or Character. This calls for specific descriptive terms such as burning,

sharp, dull, aching, gnawing, throbbing, shooting, vise-like. Use similes – “Does

blood in the stool look like sticky tar?” “Does blood in the vomitus look like

coffee-grounds?”

c. Quantity or Severity. Attempt to quantify the sign and symptom, e.g, “profuse

menstrual flow soaking five pads per hour”.

d. Timing (Onset, Duration, Frequency)

When did the symptom first appear? Or state specifically how long ago the

symptom started prior to arrival?

How long did the symptom last?

Was it steady (constant) or did it come and go during that time (intermittent)?”

e. Setting. Where was the person or what was the person doing when the symptom

started? What brings it on?

Example: “Did you notice the chest pain after carrying a heavy load, or did the

pain start by herself?”

f. Aggravating or Relieving Factors.

What makes the pain worse?

 Example: “Is it aggravated by weather, activity, food, medication, time of

day, season and son on?”

What relieves it? (e.g., rest, medication, ice pack)?

What is the effect of the treatment?

Example: “What have you tried?” or “What seems to help?”

g. Associated Factors. Is the primary symptom associated with any other symptoms

(e.g., urinary frequency and burning associated with fever and chills?) Review the

body system related to this symptom now rather than wait for the ROS.

h. Patient’s Perception. Find out the meaning of the symptom by asking how it

affects daily activities. Also ask directly, “What do you thing it means?”. This is

crucial because it alerts the nurse to potential anxiety if the person thinks the

symptoms may be ominous.

MNEMONICS

 PQRST

P: precipitating factors (What provokes the symptom?)

Q: quality (Describe the character and location of the symptoms.)

R: radiation (Does the symptom radiate to other areas of the body?)

S: severity (Ask the patient to quantify the symptom[s] on a scale of 0-10, with 0 being the

absence of the symptom and 10 being the most intense.)

T: timing (Inquire about the onset, duration, frequency, etc.)

  CLIENT OUTCOMES

C: character of the symptoms, including intensity/severity

L: location, including radiation (if present)

I: impact of the symptoms/illness on the patient's activities of daily living (ADL) and quality of

life

E: expectation (client's) of the caregiving process

N: neglect or abuse, including any signs that physical and emotional neglect or abuse plays a role

in the patient's

T: condition timing, including onset, duration, and frequency of symptoms

O: other symptoms that occur in association with the major presenting symptom

U: understanding/beliefs (client's) about the possible causation of the illness/condition

T: treatment (medications and other therapies that the patient has used to try to alleviate the

symptoms/condition)

C: complementary alternative medicine (CAM), including a description of the patient's use of

these agents or practices

O: options for care that are important to the patient (e.g., advance directives)

M: modulating factors, which precipitate, aggravate, or alleviate the patient's

symptoms/condition

E: exposure to infectious agents, toxic materials, etc.

S: spirituality, including spiritual beliefs, values, and needs. of the patient

 COLDSPA
COMPONENTS OF THE COLDSPA SYMPTOM ANALYSIS MNEMONIC

The COLDSPA example here provides a sample application of the COLDSPA mnemonic

adapted to analyze back pain.

Mneumonic Mneumonic

Character Describe the sign or symptom (feeling,

appearance, sound, smell, or taste if

applicable). "What does the pain feel like?"

Onset When did it begin?

"When did this pain start?"

Location Where is it? Does it radiate? Does it occur

anywhere else? "Where does it hurt the most?

Does it radiate or go to any other part of your

body?"

Duration How long does it last? Does it recur? "How

long does the pain last? Does it come and go

or is it constant?"

Severity How bad is it? How much does it bother you?

"How intense is the pain? Rate it on a scale of

1 to 10."

Pattern What makes it better or worse?

"What makes your back pain worse or better?

Are there any treatments you've tried that

relieve the pain?"

 Associated factors/How it Affects the client What other symptoms occur with it? How

does it affect you?

"What do you think caused it to start?

Do you have any other problems that seem

related to your back pain? How does this pain

affect your life and daily activities?"

d. Past health History 6. Current Medications and allergies

Purpose:

 (to identify all major past health problems of the client)

This includes:

 Childhood illness e.g. history of rheumatic fever (measles, mumps, rubella, chicken pox,

pertussis)

 History of accidents and disabling injuries (auto accidents, fractures, head injuries, burns,

falls)

 History of hospitalization (cause, name of hospital, time of admission, date, admitting

complaint, how the condition was treated, how the person was hospitalized, name of

physician, discharge diagnosis and follow up care)

 Serious or Chronic Illness. DM, HPN, heart disease, Ca, seizure disorder

 History of operations "how and why this done" (Type of surgery, date, name of the

surgeon
  Obstetrics history. Name of deliveries in which the fetus reached full term, number of

preterm pregnancies, number of abortions and number of children living recorded as

GTPAL Number of pregnancies (Gravidity), polio, DPT, Hep B, HPV, Hib,

pneumococcal vaccine. Note the date of last tetanus immunization, last tuberculosis skin

test and last flu shot.

 History of immunizations and allergies.

 Physical examinations and diagnostic tests.

f. Family History

The purpose:

 to learn about the general health of the client's blood relatives, spouse, and

children and to identify any illness of environmental genetic, or familiar nature

that might have implications for the client's health problems.

 Family history of communicable diseases.

 Heredity factors associated with causes of some diseases.

 Strong family history of certain problems.

 Health of family members "maternal, parents, siblings, aunts, uncles…etc.".

 Cause of death of the family members "immediate and extended family".

g. Review of Systems (ROS)

  Collection of data about the past and the present of each of the client systems.

 (Review of the client’s physical, sociologic, and psychological health status may

identify hidden problems and provides an opportunity to indicate client strength and

liabilities

 The order of examination is from head to toe. Remember that the health history

should be limited to patient statements or subject data --- factors that the person says

were or were not present.

ROS Checklist

 General. Present weight, recent weight change (gain or loss), clothing that fits more

tightly or loosely than before; weakness, fatigue, fever.

 Skin, Hair, and Nails (Hx of Skin disease-eczema, psoriasis, excessive dryness,

sweating, pruritis, hair growth and distribution, excessive bruising. Rashes, lumps, sores,

itching, dryness, color change; changes in hair or nails; changes in size or color of moles.

 Head, Eyes, Ears, Nose, Throat (HEENT).

 Head and neck: Headache, head injury, dizziness, lightheadedness. (any unusually

frequent or severe headache, stiffness of neck, limitation of motion, goiter, sore throat,

difficult swallowing, enlarge lymph node

 Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing,

double or blurred vision, halos around lights, moving black spots in the visual field spots,

specks, flashing lights, glaucoma, cataracts.

 Ears: Hearing, tinnitus, vertigo, earache, infection, discharge. If hearing is decreased, use

or nonuse of hearing aid, how loss affects daily lives, any exposure to environmental

noise, method of cleaning the ears.

 Nose and sinuses: Frequent colds, sinus pain, nasal stuffiness, discharge or itching, hay

fever, nosebleeds, sinus trouble, change in the sense of smells

 Throat (or mouth and pharynx): Condition of teeth and gums; bleeding gums;

dentures, if any, and how they fit; last dental examination; sore tongue; dry mouth;

frequent sore throats; hoarseness. Neck. Lumps, “swollen glands,” goiter, pain, stiffness.

Pattern of daily dental care

 Breasts. Lumps, pain or discomfort, nipple discharge, self-examination practices, history

of breast disease, any surgery on the breast, perform Breast self-examination, including

frequency and method use, last mammogram

 Axilla. Tenderness, lump, swelling or rash

 Respiratory. History of lung disease, chest pain with breathing, wheezing or noisy

breathing, shortness of breath, how much activity produces shortness of breath, Cough,

sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray.

Toxin or pollution exposure. Last chest x-ray study

 Cardiovascular. Precordial or retrosternal pain, palpitations, cyanosis, dyspnea on

exertion, orthopnea, paroxysmal nocturnal dyspnea “Heart trouble,” hypertension,

rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea,

orthopnea, edema, past electrocardiographic or other cardiovascular tests. Date of last

ECG or other heart tests.

 Peripheral Vascular.; leg cramps; past clots in veins; swelling in calves, legs, or feet;

color change in fingertips or toes during cold weather; swelling with redness or

tenderness. Coldness, numbness and tingling, swelling of legs (time of day, activity),

Discoloration in hands or feet (bluish red, pallor, mottling, associated with position,

especially around feet and ankles), varicose veins, Intermittent claudication (leg pain on

activity and exercise relieved by rest), thrombophlebitis, ulcers. Does the work involve

long-term sitting or standing? Avoid crossing the legs at the knees. Wear support hose.

 Gastrointestinal. Trouble swallowing, heartburn, appetite, food intolerance, nausea and

vomiting, hematemesis. Dysphagia (difficulty in swallowing, heartburn, indigestion, pain

associated with eating)

Bowel movements, color and size of stools, change in bowel habits, rectal bleeding,

rectal conditions (hemorrhoids, fistula) or black or tarry stools, hemorrhoids,

constipation, diarrhea. Abdominal pain, pyrosis (esophageal and stomach burning

sensation with sour eructation), food intolerance, flatulence, excessive belching or

passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.

History of abdominal disease (ulcer, liver or gallbladder, jaundice, appendicitis, colitis).

Use of antacids or laxatives.

 Urinary. Frequency of urination, polyuria, nocturia, urgency, burning or pain on

urination, hematuria, urinary infections, kidney stones, incontinence; in males, reduced

caliber or force of urinary stream, hesitancy, dribbling.

Dysuria, polyuria, oliguria, hesitancy or straining, narrowed stream, urine color (cloudy

or presence of hematuria), Incontinence, history of urinary disease, Pain in flank, groin,

 suprapubic region of low back. HP: Measures to avoid or treat urinary tract infections,

use of Kegel’s exercise after childbirth.

 Genital.

a. Male: Hernias, discharge from or sores on penis, testicular pain or masses, penile

discharge, lumps, hernia, history of sexually transmitted infections (STIs) or diseases

(STDs) and treatments, testicular self-examination practices. Sexual habits, interest,

function, satisfaction, birth control methods, condom use, problems. Concerns about

HIV infection. HP: Perform testicular examination? How frequent?

b. Female: Age at menarche; regularity, frequency, and duration of periods; amount of

bleeding, bleeding between periods or after intercourse, last menstrual period;

dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms,

postmenopausal bleeding. In patients born before 1971, exposure to diethylstilbestrol

(DES) from maternal use during pregnancy. Vaginal discharge, itching, sores, lumps,

STIs and treatments. Number of pregnancies, number and type of deliveries, number

of abortions (spontaneous and induced), complications of pregnancy, birth control

methods. Sexual preference, interest, function, satisfaction, problems (including

dyspareunia). Concerns about HIV infection. HP: Last gynecologic check-up and last

Papanicolaou test.

 Musculoskeletal. Muscle or joint pain, stiffness, swelling, arthritis, gout, backache. If

present, describe location of affected joints or muscles, any swelling, redness, pain,

tenderness, stiffness, weakness, or limitation of motion or activity; include timing of

symptoms (e.g., morning or evening), duration, and any history of trauma. Joint pain with
 systemic features such as fever, chills, rash, anorexia, weight loss, or weakness. Neck or

low back pain: any pain (location and radiation to extremities),

History of arthritis or gout

In the joints: pain, stiffness, swelling (location, migratory nature), deformity, limitation of

motion, crepitus (noise with joint motion)

In the muscle: any pain, cramps, weakness, gait problems, problems with coordinated

activities)

In the back: Any pain (location and radiation to extremities, stiffness, limitation of

motion, history of back pain or disk disease.

HP: How much walking per day? What is the effect of limited range of motion on daily

activities such as grooming, feeding, toileting, dressing? Are any mobility aids used?

 Psychiatric. Nervousness; tension; mood, including depression, memory change, suicide

attempts, if relevant.

 Neurologic. Changes in mood, attention, or speech; changes in orientation, memory,

insight, or judgment; headache, dizziness, vertigo; fainting, blackouts, seizures,

weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,”

tremors or other involuntary movements, seizures.

HP: Interpersonal Relationships and coping patterns

 Hematologic. Anemia, easy bruising or bleeding, past transfusions, transfusion reactions

 Endocrine. “Thyroid trouble,” heat or cold intolerance, excessive sweating, excessive

thirst or hunger, polyuria, change in glove or shoe size, abnormal hair distribution,
 nervousness tremors, need for hormone therapy. History of diabetes or diabetic

symptoms

h. Functional Assessment (Including A

a. Self-esteem, Self-concept (Educational attainment and trainings, Financial status

(income), Religious practices and perception of personal strengths (value-belief

system)

b. ADLs (Actvities of Daily Living); Usual daily activities; Ability to perform ADLs

(independent or needs assistance with feeding, bathing, hygiene, dressing, toileting,

bed to chair transfer, walking, standing or climbing stairs; Any use of wheelchair,

prostheses or mobility aids? Leisure activities enjoyed; Exercise pattern (type,

amount per day or week, method of monitoring the body’s response to exercise)

c. Sleep/rest (sleep patterns, daytime naps, any sleep aids –sleeping pills, CPAP for

sleep apnea/snoring)

d. Nutrition/problems with diet, weight/ Elimination. Diet recall--- 24-hour recall,

Eating habits and current appetite, Food allergies and intolerance, Daily intake of

caffeine, Usual pattern of bowel with mobility or transfer in toileting continence, use

of laxatives.

e. Personal habits. Tobacco, Alcohol, Street Drugs:

Tobacco Use: “Do you smoke cigarettes?”, “At what age did you start? How many

packs do you smoke per day? How many years have you smoked? Have you ever

tried to quit? How did it go? Smoking history (in pack years)
 Alcohol: Do you drink alcohol? When was your last drink of alcohol? How much did

you drink that time? Out of the last 30 days, about haw many days would you say that

you drink alcohol? Have you ever had a drinking problem? Do you have a history of

alcohol treatment? Do you have a history of family member with problem drinking?

CAGE Test (Ewing, 1984) Screening Questionnaire to identify excessive or

uncontrolled drinking.

C –ut down (Have you ever thought that you should cut down your drinking?)

A – nnoyed (Have you ever been annoyed by criticism of your drinking?)

G- uilty (Have you ever felt guilty about your drinking?

E- ye opener (Do you drink in the morning?”

If the person answers “yes” or “no” to two or more CAGE questions, suspect

alcohol abuse

If the person answers “no” to drinking alcohol, ask the reason for this decision

(e.g, psychological, legal, health, religion)

Illicit/Street Drugs (Exercise great caution when asking questions about use of

drugs). Ask specifically about marijuana, cocaine, amphetamines and barbiturates

Frequency of use and how has usage affected work or family.

i. Environment/Hazards

 Housing and Neighborhood.

 Safety of area

 Adequate ventilation and utilities

 Access to transportation

 Involvement in community services

 Hazards in workplace, at home.

j. Intimate Pattern: Violence

Begin with open-ended questions

Ask: How are things at home?

Do you feel safe?

If the person responds to feeling unsafe, follow-up with close-ended questions.

Ask: Have you ever been emotionally or physically abused by your

partner or someone important to you? Within the last year, have you been

hit, slapped, kicked, pushed or shaved or otherwise physically hurt by your

partner or ex-partner?

If yes, by whom?

Number of times?

Does your partner ever force you into having sexual intercourse?

Are you afraid of your partner or ex-partner?

k. Occupational Health

Ask the patient to describe his or her job

Ever worked with any health hazard such as inhalants, chemicals? Wear any

protective equipment? Any work programs in place that monitor exposure? Aware of

any health problem now that may be related to work exposure?